James Madison University Transitional Duty Plan

Employee Name:	Date:
Position Title:

I. Medical Information
Current Medical Restrictions:
Date Restrictions Began:	Next Medical Appointment:

Transitional Plan Describe the specific duties/tasks that will be assigned Percentage (%) of physical, mental, and environmental demands required to perform the duty/task.
Plan Start Date: Evaluation Date:
A. Specific Duties	B. Modifications
Example: Lift up to 50 lbs.	Example: Can’t lift more than 15 lbs. Any lifting over 15 lbs. will be with assistance
Comments/Special Considerations:

III. Signatures of Agreement
I understand the plan and have been provided with a copy of the plan and information sheet. Should I experience any difficulties during my transitional duty, I will discuss them with my supervisor. Employee Signature Supervisor Signature _ Date Date

Please sign and forward to Human Resources MSC 7009, ATTN: Benefits Specialists.

James Madison University Transitional Duty Information Sheet

It is the policy of the University to accommodate employees with injuries/illnesses when they have been placed on restricted (light) duty. Restrictions are evaluated on an individual basis.

A Transitional Duty Plan will be agreed upon and put into action by the employee, supervisor, physician and Human Resources.

If the plan is in effect, and the plan becomes obsolete (for example, new duties are added or the plan is not working) any one of the parties may request that the plan be revisited.

Steps for Transitional Duty

Step 1 – If an employee is on the seventh calendar of day restrictions after an injury or illness or returns from sick leave with restrictions a transitional duty plan must be completed.

Step 2 – The injured employee takes a “Physical Capabilities” form (http://www.covwc.com) with them to the Physician, or the Physician may use their own form. The physician details the physical limitations that are in place, the length of time they are in place, and when the next medical appointment is scheduled.

Step 3 – The employee and supervisor will complete the form utilizing the Employee Work Profile – Addendum A and the “Physical Capabilities” form to determine which duties the employee may perform while on the Transitional Duty Plan. If there are needs in other areas of a department, and the employee has the skills and abilities to meet the requirements of the job, then the employee may temporarily transfer to another position.

Step 4 – The Transitional Duty Plan and any revisions are to be signed by both the employee and the supervisor and submitted to the Human Resources Benefits Specialist.

Step 5 – The plan will be revisited periodically to evaluate its effectiveness. Usually, the best time to do this is after doctor appointments. A new plan will be submitted to the Benefits Specialist if there are any changes to the restrictions.

Questions regarding the Transitional Duty Plan may be directed to the James Madison University’s Human Resource Office Benefits Specialists at benefits@jmu.edu.